SLEEP RELATED MORTALITIES IN

VERY EARLY LIFE. HOW CAN WE

HELP?Samuel Dzodzomenyo MD.

OVERVIEW

The role of unsafe sleep in infant mortality

Understanding sleep-environment-related infant deaths.

Preventing sleep-environment-related deaths

OBJECTIVES1.To identify risk factors associated with

sleep related mortality in infants

2. Understanding sleep-environment-related infant deaths.

 3.Best practices to reduce sleep related

infant death.

INFANT MORTALITY RATE:GLOBAL The number of infant deaths (one year

of age or younger) per 1000 live births Currently, the most common cause is

pneumonia. Traditionally, the most common cause

worldwide was dehydration from diarrhea

INFANT MORTALITY RATERank Country

Infant mortality rate(deaths/1,000 live births)

1 Angola 180.212 Sierra Leone 154.433 Afghanistan 151.954 Liberia 138.245 Niger 116.66219 Hong Kong 2.92220 Japan 2.79221 Sweden 2.75222 Bermuda 2.46223 Singapore 2.31

INFANT MORTALITY RATE: US

-6.84 in 2003-6.78 in 2004-Range: 4.67 (Asian & Pacific Islanders)-13.6 (Non-Hispanic Blacks)

IMR United States/100,000

INFANT MORTALITY IN THE US:LEADING CAUSES

1. Congenital malformations2. Low birth weight3. SIDSTogether account for 45% of all infantdeaths

Infant Mortality Rate (Deaths per 1,000 Live Births) by Race/Ethnicity, Linked Files, 2004-2006

  OH US

Non-Hispanic White 6.4 5.7

Non-Hispanic Black 15.9 13.5

Hispanic 5.6 5.5Total 7.8 6.8

(show/hide notes)

MONTGOMERY COUNTY(OH)

Ohio’s infant mortality rate of 7.7 per 1,000 births ranked eighth worst in the country in 2008. Montgomery County’s infant mortality rate that year was slightly higher at 8 per 1,000 births.

-Indicator of health of present and future Populations- Indicator of health disparities among different populations- Indicator of overall health/ quality of life in a community

WHY LOOK AT INFANT MORTALITY?

WHAT IS SUDDEN INFANT DEATH SYNDROME (SIDS)?

SIDS is the unexpected death of seemingly healthy babies 12 months or younger.

No cause of death is determined by Death scene investigation and autopsy.Review of baby’s medical history.

Experts cannot predict which babies will die from SIDS.

Revised – 12/08

MONTGOMERY COUNTY (OH) 2009: 4 deaths where sleep

environment was determined to be a possible contributing factor but there was not enough information for the Coroner’s office to call it. 

4 more deaths identified “position asphyxia” on the death certificate, so those are the easy ones!  

2010: 3 sleep-related deaths for – one positional, one overlay and one “ unsafe sleeping”

SIDS FACTS The exact causes of SIDS are unknown, but

SIDS is NOT caused by ImmunizationsVomiting or choking

Revised – 12/08

DO WE HAVE THEORIES? Glial-neuronal interactions in the cardio-

respiratory centre of the brainstem. Gastric reflux, and especially

laryngopharyngeal reflux Role of serotonin in respiratory function

and dysfunction Reduced ventilatory response to CO2

challenge in the prone position Impaired ability to respond to

respiratory compromise

Fast Facts About SIDS

SIDS is one of the leading causes of death in infants between 1 month and 1 year of age.

Most SIDS deaths happen when babies are between 2 months and 4 months of age.

African American babies are more than 2 times as likely to die of SIDS as white babies.

American Indian/Alaskan Native babies are nearly 3 times as likely to die of SIDS as white babies.

SIDS IN CHILD CARE Two thirds of US infants younger than

1 year are in nonparental child care. Infants of employed mothers spend an

average of 22 hours per week in child care. 32% of infants are in child care full time. Less than 9% of SIDS deaths should

occur in child care.Ehrle et al, 2001

Revised – 12/08

SIDS IN CHILD CARE Approximately 20% of SIDS deaths occur

while the infant is in the care of a nonparental caregiver.60% in family child care20% in child care centers20% in relative care

Infants tend to be Caucasian, with older, more educated parents.

Moon et al, 2000

Revised – 12/08

SIDS IN CHILD CARE Approximately 1/3 of SIDS-related deaths in

child care occur in the first week, and 1/2 of these occur on the first day.

Something intrinsic to child care? Not that we’ve found yetStress, sleep deprivation?

Unaccustomed tummy sleeping? Yes

Revised – 12/08

THE TRIPLE RISK MODEL

-Requires the convergence of threeelements that may lead to the death ofan infant from SIDS:1. Critical developmental period2. Vulnerable infant3. Outside stressor(s)-All three elements must be present forSIDS to occur.-Removing one or more outside stressorscan reduce the risk of SIDS.

TRIPLE RISK MODEL

SIDS

Critical development period

External stressors

Vulnerable infant

Revised – 12/08

OUTSIDE STRESSORS

-Stomach sleep position-Soft bedding-Tobacco smoke-Overheating-Infection

SIDS RISK FACTORS—PREGNANCY Low birth weight (less than 5 pounds) Premature (less than 37 weeks) Maternal smoking during pregnancy Multiple births (eg, twins, triplets) Maternal age younger than 18 years Less than 18 months between births

BABIES AT RISK FOR SIDS African Americans (2x greater risk)

Partly geneticPartly behavioral (sleep position,

bedsharing) American Indians (more than 2x greater

risk)Secondhand smoke exposureBinge alcohol drinking during pregnancyOverdressing of babies

BABIES AT RISK FOR SIDS

• Mothers who smoke during pregnancy (3x greater risk)

• Babies who breathe secondhand smoke (2.5x greater risk)

• Babies who sleep prone (on their tummies) or on their sides (2-3x greater risk)

• Babies put on their tummies to sleep who usually sleep on their backs or babies who roll over onto their tummies (as much as 18x)

HEALTHY CHILD CARE AMERICA BACK TO SLEEP CAMPAIGN

Launched in 2003 Activities

Increase awareness.Decrease incidence of SIDS in child care.Educate policy makers to include back-to-sleep

positioning in child care regulations.

Revised – 12/08

SIDS RATE AND SLEEP POSITIONSIDS Rate and Sleep Position, 1988-2003

(Deaths per 1,000 Live Births)

1.4 1.391.3 1.3

1.2 1.17

1.03

0.870.74 0.72 0.67 0.62

0.56 0.57 0.53

0.77

53.135.3

38.6

26.9

1317

55.7

64.4 66.671.6 71.1 72.8

0

0.5

1

1.5

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

Year

SID

S R

ate

0

50

100

Perc

ent B

ack

Slee

ping

Source: National Institute of Child Health and Human Development Household Survey Final Data 2003, National Center for Health Statistics, Centers for Disease Control and Prevention

SIDS rates have decreased and percent of back sleeping has increased since the campaign began.

Yellow (1985–1991): Pre-AAP recommendationBlue (1992–1994): Post-AAP recommendationRed (1995–1999): Back to Sleep campaign

Revised – 12/08

REASONS THAT PEOPLE PLACE BABIES ON THEIR TUMMIES

They think that babies are more likely to choke or aspirate if they vomit or spit up

They are worried that babies won’t sleep as well

When babies sleep on the backs, they don’t develop normally.

The baby’s parent(s) wants the baby to sleep on the tummy

Revised – 12/08

Reasons that people place babies on their tummies

Babies sleep better/longer/more deeply when they’re on their stomachs.

The baby will get a flat head if the baby sleeps on the back.

The baby will get a bald spot from sleeping on the back.

When the baby is on the back, s/he startles more easily and wakes up.

Revised – 12/08

ANATOMY WHEN SLEEPING ON STOMACH

Revised - 0408

ANATOMY WHEN SUPINE

Revised – 12/08

WHY CHILD CARE PROVIDERS USE TUMMY SLEEPING

Lack of awareness25% of licensed child care providers say they

never heard of the relationship between SIDS and sleep position.

Misconceptions about risk of sleep positionSupine and aspiration, chokingBelief that tummy sleeping improves infant

comfort Parental preference

Lack of informationLack of educationRevised – 12/08

IMPLEMENTING SIDS RISK REDUCTION

Tummy to play and back to sleep. Use safe sleep practices. Provide a safe sleep environment.

Revised – 12/08

TUMMY TO PLAY AND BACK TO SLEEP Supervised tummy time when babies

are awakePromotes healthy physical and brain

developmentStrengthens neck, arm, and shoulder musclesDecreases risk of head flattening and baldingEncourages bonding and play between the

supervising adult and the baby Back to sleep

Reduces the risk of SIDSComfortable and safe

Revised – 12/08

Tummy Time• Tummy time is for babies who are

awake and being observed.• It is needed to develop strong

muscles.• Have tummy time 2 to 3 times a

day and increase the amount of tummy time per day as the baby gets stronger.

• There are lots of ways for babies to enjoy tummy time!Revised – 12/08

SAFE SLEEP PRACTICES Avoid overheating.

Do not overdress baby.Never cover baby’s head with a blanket.Room temperature should be comfortable for a

lightly clothed adult.

Revised – 12/08

SAFE SLEEP PRACTICES Always put healthy babies to sleep on their

backs for naps and at bedtime. Do not have more than one baby per crib.

Revised – 12/08

SAFE SLEEP PRACTICES Pacifiers may be offered to babies to reduce

the risk of SIDS If breastfed, wait until breastfeeding is well

established (approximately 3 - 4 weeks of age), before offering a pacifier.

If the baby refuses the pacifier, don’t force it. If the pacifier falls out while the baby is asleep,

you do not have to re-insert it.

Revised – 12/08

SAFE SLEEP ENVIRONMENT Safe crib, firm mattress. Avoid chairs, sofas, air mattresses, water

beds, and adult beds.

Revised – 12/08

BED SHARING OR CO-SLEEPING May be hazardous under certain

conditions. The American Academy of Pediatrics

recommends that babies not bed share. Bed sharing is especially dangerous

when Baby bed shares with someone other than the

parents. Therefore, children or other adults should not bed sharing with an infant.

Bed sharing occurs on a waterbed, couch, or armchair.

The adult is a smoker. The adult drinks alcohol or uses medications or

drugs that can make it more difficult to arouse or wake up.

Revised – 12/08

BED SHARING OR CO-SLEEPING The safest place for a baby to sleep is in a

separate sleep surface (eg, bassinet, crib, cradle) next to the parents’ bed.

Revised – 12/08

SAFE SLEEP ENVIRONMENT No excess bedding, comforters, or

pillowsConsider a blanket sleeper or sleep sack for

the baby instead of a blanket if extra warmth is needed

No bib around the baby’s neck Bumper pads are not needed Wedges or positioners are not

recommended No toys or stuffed animals in the crib Be aware that parents like their baby to

have things from home with them- help caregivers to identify other ways to allow this.

Revised – 12/08

SAFE SLEEP ENVIRONMENT Maintain a smoke-free environment

Revised – 12/08

The Montgomery County Child FatalityReview Board (CFRB) is charged with preventinginfant deaths in our community. The goal is toraise awareness about unsafe sleep practicesthat lead to the death of infants less than oneyear of age.In Montgomery County nearly one baby amonth dies due to unsafe sleep practices.

MCCFRB

MONTGOMERY COUNTY(OH)

Ohio’s infant mortality rate of 7.7 per 1,000 births ranked eighth worst in the country in 2008. Montgomery County’s infant mortality rate that year was slightly higher at 8 per 1,000 births.

MONTGOMERY COUNTY 2009: 4 deaths where sleep

environment was determined to be a possible contributing factor but there was not enough information for the Coroner’s office to call it. 

4 more deaths identified “position asphyxia” on the death certificate, so those are the easy ones!  

2010: 3 sleep-related deaths for – one positional, one overlay and one “ unsafe sleeping”

The ABCs of Safe Sleep.I sleep safest.Alone on my Back in a Crib.

MCCFRB

Your baby should always sleepALONE.-Some Moms and Dads sleep with their babies in an adult bed. Or, they allow babies to sleep with other children or pets. This is not safe. ----Baby’s mouth or nose can become covered, keeping the baby from breathing.- Your baby should sleep alone in a safe,empty crib.- Baby’s caregiver should be nearby, in thesame room, but not in the same bed.- If your baby is in your bed to feed orcomfort, put your baby in the crib for sleep.

A

Your baby should always be on hisor her BACK to sleep.The safest position for babies to sleep is ontheir backs. (Your baby should always sleepon his or her back unless your doctor hasinstructed you otherwise for medical reasons.)• Keep baby’s room at 68 – 72 degrees.Not too warm. Not too cold.• Have baby in a one-piece sleeper or sleep sack. Baby will stay warm and comfortable.No blankets needed.• Keep the room smoke-free!

B

In a safe empty CRIB with afirm mattress.A safe crib is the best place for your babyto sleep. It is not safe for a baby to sleep inan adult bed, on a couch, chair, bean bag,waterbed, featherbed, futon or recliner.A safe crib has:• A firm mattress that fits the headboardand footboard tightly with no gaps.• A sheet and mattress that fit tightly.• No corner posts or cutouts in theheadboard or footboard.• No missing slats. Also, slats are not morethan 2 and 3/8 inches apart (about thewidth of a soda pop can).• No pillows, bumper pads, quilts, lambskins, blankets, or stuffed toys.

C

More information about safe sleep is in the Safe Sleep for your Baby brochure.You can find it at www.phdmc.org orby calling 937-225-4981.

BENEFITS OF A SAFE SLEEP POLICY

May save lives of babies Shows parents baby’s health and safety is

your #1 priority Educates staff

Consistent careEducate parentsProfessional development

Revised – 12/08

BENEFITS OF A SAFE SLEEP POLICY It empowers child care providers If followed, helps reduce your risk of liability

Revised – 12/08

ELEMENTS OF A SAFE SLEEP POLICY Healthy babies always sleep on their backs. Obtain physician’s note for non–back sleepers.

The note should include prescribed sleep position and the medical reason for not using the back position.

Use safety-approved cribs and firm mattresses. Crib: free of toys, stuffed animals, and excess

bedding. If blankets are to be used, practice feet-to-foot

rule. Sleep only one baby per crib.

Revised – 12/08

ELEMENTS OF A SAFE SLEEP POLICY

Room temperature is comfortable for a lightly clothed adult.

Monitor sleeping babies. Have supervised tummy time for awake

babies.

Revised – 12/08

Elements of a Safe Sleep Policy

• Teach staff, substitutes and volunteers about safe sleep policy and practices.

• Provide parents with safe sleep policy.

Revised – 12/08

Alternate Sleep Position• Inform all child care providers and

substitutes.• Keep physician’s note in baby’s

medical file and post notice on crib.

Revised – 12/08

HANDLING PARENTS’ CONCERNS Discuss SIDS and risk reduction strategies

with parents. Discuss sleep position policies. Discuss medical waiver and implications.

Revised – 12/08

WHAT WE NEED TO DO Implement the Caring for Our Children

standards. Have a safe sleep policy. Train all caregivers. Talk with a child care health consultant. Be able to handle an infant medical

emergency. Be aware of bereavement resources.

Revised – 12/08

HANDLING A MEDICAL EMERGENCY Have a plan in place. Review the plan with all staff periodically. Be sure you have received training and

have successfully practiced rescue breathing and skills for handling a blocked airway for infants in a first aid course.

Revised – 12/08

FIRST AID—UNRESPONSIVE INFANT Teaching resuscitation skills is beyond the

scope of this workshop. You must first practice resuscitation on a mannequin.

Call 911. Get help to care for the other children. Call the child’s parents or emergency contact. Call the parents of the other children. Do not disturb the scene (e.g., don’t try to tidy

up). Notify licensing agency and insurance agency.

Revised – 12/08

WHAT TO EXPECT IF A BABY DIES Investigation

Several people will ask for the same information so they can help.

Law enforcementNote baby’s health, behavior, etc.Take photos.Limit disturbance of the area.

Revised – 12/08

WHAT TO EXPECT IF A BABY DIES Licensing agency

Questions about licensing regulations.SIDS death not a reason for revoking a license.

Coroner/medical examinerConducts autopsy.Determines cause of death.

Revised – 12/08

Social HistoryFamily Information,Child Caregivers,Social Services, ChildProtective Services,Other

Scene InformationPolice, ForensicInvestigator, EMS,Other

Infant Death Investigation?Comprehensive Forensic Investigation of Infant Death.

Infant Death Investigation?Comprehensive Forensic Investigation of Infant Death.

Medical HistoryPre-Natal and BirthHistory, Pediatric andPrimary Care History,OtherForensic AutopsyExternal, Internal &Histological Examination,Toxicological andMicrobiological Tests,Metabolic

SUMMARY What SIDS is SIDS risk factors How to reduce the risk Caring for Our Children: National Health

and Safety Performance Standards Developing a safe sleep policy for your

program Handling a medical emergency Resources for more information

Revised – 12/08

HEALTHY CHILD CARE AMERICA BACK TO SLEEP CAMPAIGN

• American Academy of Pediatrics141 Northwest Point BlvdElk Grove Village, IL 60007-1098Phone: 888/227-5409 Fax: 847/228-7320E-mail: childcare@aap.orgWeb site: www.healthychildcare.org

Revised – 12/08

PARTNERS AND RESOURCES

Back to Sleep campaignwww.nichd.nih.gov/sidsPhone: 1-800-505-CRIB (2742) You can receive informational brochures,

posters to provide to families and child care providers

Revised – 12/08

PARTNERS AND RESOURCES First Candle/SIDS Alliance

1314 Bedford Ave, Suite 210, Baltimore, MD 21208Phone: 800/221-7437 or 410/653-8226Fax: 410/653-8709E-mail: info@firstcandle.orgWeb site: www.firstcandle.org

National SIDS and Infant Death Program Support Center112 E Allegan, Suite 500, Lansing, MI 48933Phone: 800/930-SIDS or 800/930-7437E-mail: info@sidsprojectimpact.comWeb site: www.sidsprojectimpact.com

Revised – 12/08

PARTNERS AND RESOURCES National SIDS/Infant Death Resource Center

866/866-7437, www.sidscenter.org CJ Foundation for SIDS

888/8CJ-SIDS (825-7437), www.cjsids.com

Revised – 12/08

SAFE SLEEP EDUCATION IS INEXPENSIVE AND CAN BE DONE IN MANY SETTINGS Public health clinics Home visiting programs Hospitals—in L&D, pediatric units and outpatient clinics, EDs, OB clinics Emergency services Churches Community organizations But it’s not easy – we must move “Beyond Basic Brochure Distribution”

SAFE SLEEP EDUCATION

Is needed to change social norms about sleep-environment-related risks Needs to be addressed early and often! Must involve credible “key informants” or “key influencers” Should be institutionalized in settings such as newborn nurseries and pediatrics. Must address barriers to adoption and opposing messages Must be repeated and reinforced – at the community level

SAFE SLEEP EDUCATION FORTHE PROVIDER AND PUBLIC SAFETY COMMUNITY Police and EMS personnel, if educated, can provide us with essential information Such as the presence and/or use of a crib; sleep position, etc Day care providers,baby sitters, grandparents ,

and others who care for infants must be included Physicians, nurses, child birth educators and social services providers are valuable influencers The child passenger safety community (can integrate infant sleep safety and installation of infant safety seats) The media